Tag: traumatic brain injury

Making boxing safer: when to stop a fight on medical grounds

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Making boxing safer: when to stop a fight on medical grounds
N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America

Corresponding author: N K Sethi (sethinitinmd@hotmail.com

Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.

Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065

 

 

 

Recently the boxing world was heart broken by the untimely demise of boxer Patrick Day. By the accounts of all who knew him, Patrick was an intelligent well-spoken young man who was loved by all. He died at the tender age of 27 after suffering devastating traumatic brain injury (TBI) during the course of a professional boxing bout. Patrick was no rookie stepping into the ring for the first time. He was an accomplished boxer with a record of 17 wins and 4 losses in professional boxing. His amateur record was 75-5.

Following Patrick’s death, the boxing community has been looking inwards and searching for answers on what went wrong that eventful night and what can be done to prevent such tragedies in the future. Unfortunately, there are no easy answers. In a sport where every punch thrown at the head is thrown with the intention of winning by causing a knock-out (KO) (aka a concussion); the risk of TBI lurks all the time. Many still do not understand that deaths when they do occur in the ring are not the result of a single blow (punch) to the head; rather it is the culmination of multiple head shots which the fighter sustains during the course of the bout. Importantly the initial signs of a concussion/TBI are subtle and wholly subjective. The fighter may experience a headache, subjective feeling of dizziness or imbalance, vision problems and difficulty in focusing. There are no objective signs which can help the ringside physician, the referee, the inspectors and the corner men identify the concussion/TBI with confidence. By the time objective signs such as gross motor instability (GMI) (obvious balance problems, lack of coordination or inequality in pupil size) appear, the TBI is usually well evolved and precious little can be done ringside to save the boxer’s life except to transport him to the hospital in an emergent fashion for life saving brain surgery. Usually a decompressive hemicraniectomy is carried out for evacuation of the blood clot and to reduce the intracranial pressure. Even though surgery in some of these cases may save the boxer’s life, he is usually left behind with significant and permanent neurological deficits such as motor weakness, speech and cognitive deficits and problems with coordination and gait. Hence the goal should remain to stop a fight early rather than late. A good stoppage done by the referee or the ringside physician on medical grounds is one which is done for the right indication such as concern for TBI and at the right time (neither too early, certainly never too late!).

Standardizing medical stoppages in the ring is no easy task but certainly something which we all should be paying closer attention to. One approach which can be adopted is to establish NO-GO criteria in boxing. If any of the NO-GO criteria are encountered during the course of the bout, the bout should be stopped on medical grounds to protect the health and safety of the boxer. Ringside physicians, referee, the Commission officials, the corner men and most importantly the two boxers should be aware of these NO-GO criteria.

In order to identify and prevent acute TBI in boxing, the following good practice guidelines and NO-GO criteria are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:

The fight should be stopped if the boxer voices any of these complaints or displays any of these signs at any time during the course of the fight:

1. If the boxer voices complaint of headache.
2. If the boxer is displaying overt signs of a concussion and gross motor instability (GMI). These signs include but are not limited to confusion and disorientation, impaired balance and coordination.
3. If the boxer suffers any duration of loss of consciousness after a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
4. If the boxer suffers an impact seizure or displays fencing responses at the time of a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
5. The boxer suffers loss of visual acuity during the course of a fight. This is usually on account of trauma to the eye. Loss of visual acuity results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer.
6. The boxer suffers loss or restriction of visual field during the course of a fight. This may be on account of trauma to the eye, neural mechanisms which control eye-movements or due to swelling around the eye (peri-orbital swelling). Restriction of visual fields results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer
7. If the boxer becomes a physically compromised fighter during the course of a fight. This usually occurs on account of injury to the hands/shoulders or the lower extremity (knee or ankle injury) leading to inability to defend oneself from the opponent.
8. If the boxer starts to vomit during the course of the bout, the fight should be stopped (caveat is that boxers will sometime vomit after a hard body or liver shot).

 

Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

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Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

Nitin K Sethi, MD, MBBS, FAAN
Chief Medical Officer, New York State Athletic Commission
Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY 10065 (U.S.A.)

Disclaimer: the views expressed in this article are mine and do not necessarily reflect the views of the New York State Athletic Commission (NYSAC).

 

In the ring and cage during a fight:

1. If concern for concussion or traumatic brain injury arises during the course of the bout, the ringside physician shall assess the combatant preferably between the rounds. The evaluation will be carried out by the ringside physician during the 1-minute break between rounds or after the 1-minute break but before commencement of the next round by requesting the referee to call a time out. The ringside physician shall assess the combatant with the use of Maddocks questions. Maddocks questions include but are not restricted to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

2. The ringside physician shall conduct a focused neurological evaluation of the combatant in the ring/cage. This evaluation shall include:

–asking the combatant if he/she has any subjective complaints such as headache, dizziness, visual disturbances, nausea, feeling off-balance.
–giving the combatant a two-step command (touch your right ear with your left glove).
–assessment of pupil size symmetry and reactivity (integrity of cranial nerves II and III)
–assessment of extraocular movements (integrity of midbrain and pons by assessment of cranial nerves III, IV and VI)
–assessment of cerebellar function and infratentorial compartment integrity by checking gait and stance (stand still with feet together and/or tandem gait).

The ringside physician should be aware of the NO-GO criteria. If any one of the NO-GO criteria is present, consult with Chief Medical Officer (CMO)/Assistant Chief Medical Officer (ACMO) and consider advising the referee to stop the fight on medical grounds.

The NO GO criteria are the following:

1. If the combatant exhibits any period of LOC or unresponsiveness after a KO.

2. if the combatant exhibits confusion (any disorientation or inability to respond appropriately to questions) at time of assessment by ringside physician.

3. If the combatant exhibits amnesia (retrograde / anterograde) when assessed by the ringside physician. The ringside physician shall assess for retrograde and anterograde amnesia in the ring/cage using Maddocks questions including but not limited to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

4. If the combatant voices to the ringside physician or his corner any new and/or persistent subjective symptoms such as headache, nausea, dizziness.

5. If the combatant vomits during the course of the fight (this criterion should not be used in isolation to stop a fight on medical grounds).

6. If the combatant has an abnormal neurological examination (ataxia, impaired balance, pupil size asymmetry and/or reactivity) when assessed by the ringside physician.

7. If the combatant has a concussive seizure also at times referred to as an impact seizure (seizure occurring at the time the fighter’s head makes impact with the ring/cage canvas).

 

In the post-fight examination area/locker room after the fight is over

The ringside physician shall assess for the presence or absence of concussion/ traumatic brain injury with the aid of a multimodal concussion screening and assessment battery including but not limited to:

a) Glasgow Coma Scale Score (best motor response, best verbal response and eye-opening). CGS score less than 13 is mandatory transfer to the emergency department (ED) of the designated Level I Trauma Center via on-site ambulance for urgent CT scan head to rule out acute traumatic brain injury.
b) Detailed neurological examination including higher mental function testing, cranial nerve II to XII testing, pronator drift testing, assessment of motor function, finger to nose testing, tandem gait assessment and Rhomberg’s test.
c) Standardized Assessment of Concussion (SAC) test-check orientation, immediate memory, concentration, delayed recall (see attached SAC form).
d) Balance Error Scoring System (BESS) test-double leg stance, single leg stance and tandem leg stance (see attached BESS testing procedure).

Management of a concussed combatant is on a case by case basis with majority of combatants discharged from the venue with a medical suspension. Duration of the suspension may vary from 30 to 90 days with mandatory 90-day suspension and follow up with a neurologist if the concussion occurred by a KO. All combatants discharged home from the venue are instructed to remain in close observation of a family member/coaching staff for the next 24 hours with instructions to report to the nearest emergency department (ED) if any neurological symptom (headache, dizziness, blurred vision, vomiting, impaired balance) or sensorium (lethargy, unresponsiveness) is reported. All discharged combatants are educated about post-concussion symptoms with instructions to seek medical care if these are reported. A combatant may be referred to the ED of the nearest Level I trauma center for an urgent CT scan of the head and further evaluation if deemed appropriate by the ringside physician. Transport in these cases shall take place via on site ambulance.

References

 

1. Neidecker J, Sethi NK, Taylor R, Monsell R, Muzzi D, Spizler B, Lovelace L, Ayoub E, Weinstein R, Estwanik J, Reyes P, Cantu RC, Jordan B, Goodman M, Stiller JW, Gelber J, Boltuch R, Coletta D, Gagliardi A, Gelfman S, Golden P, Rizzo N, Wallace P, Fields A, Inalsingh C. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.Br J Sports Med. 2019;53(6):328-333. doi: 10.1136/bjsports-2017-098799.

2. Erlanger DM. Exposure to sub-concussive head injury in boxing and other sports. Brain Inj. 2015;29(2):171-4. doi: 10.3109/02699052.2014.965211.

3. Jayarao M, Chin LS, Cantu RC. Boxing-related head injuries. Phys Sportsmed. 2010;38(3):18-26. doi: 10.3810/psm.2010.10.1804.

4. Galetta KM, Barrett J, Allen M, Madda F, Delicata D, Tennant AT, Branas CC, Maguire MG, Messner LV, Devick S, Galetta SL, Balcer LJ. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology. 2011 Apr 26;76(17):1456-62. doi: 10.1212/WNL.0b013e31821184c9.

5. Potter MR, Snyder AJ, Smith GA. Boxing injuries presenting to U.S. emergency departments, 1990-2008.Am J Prev Med. 2011 Apr;40(4):462-7. doi: 10.1016/j.amepre.2010.12.018.

6. Sawauchi S, Murakami S, Tani S, Ogawa T, Suzuki T, Abe T. Acute subdural hematoma caused by professional boxing. No Shinkei Geka. 1996 Oct;24(10):905-11.

Can boxing be made safer? Yes but the culture needs to change

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N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America

 

 

Disclosure and Disclaimer: N.K Sethi serves as Chief Medical Officer for the New York State Athletic Commission (NYSAC). The views expressed are his only and do not reflect the views of the NYSAC.

KEY WORDS: boxing; traumatic brain injury; concussion; death

 

 

Recently the boxing world has been mourning the loss of a number of boxers in the ring or in the immediate aftermath of a bout.  As physicians we take an oath to always protect the health of our patients and while ringside medicine is practiced in a different arena than within the confines of a hospital or ER, our duties and obligations to protect the health and safety of the fighters should never waiver for when they enter that ring or cage, they entrust us with their most precious possession of health. Few realize the pressures doctors work under at ringside. Once I had to make the difficult decision to stop a bout on medical grounds with only 30 seconds left on the clock in the last round. I stopped the fight only to be berated by the fighter’s corner like I have never been before. The F word was used repeatedly for what I had done and I was told in rather colorful language of what they thought of my action. I remained calm and stepped away after ensuring the fighter was safe.

 

As I see it, when I “hung up my gloves” at the end of a long night, I had the satisfaction of knowing that I had done the job which I am entrusted with to the best of my capability. That job is to protect my fighter first and foremost. As a fan, yes I may see it differently and want the fight to go down to the end but we are not there in the capacity of a fan of the sport, we are there as doctors with one and only one job to protect the fighter.

 

Yes 30 seconds in boxing do matter. In boxing one punch can be the difference between life and death. One punch can kill! So while we as ringside physicians endure the wrath of the corners, the media and sometimes the fighter himself let us not let this discourage or intimidate us to comprise on fighter safety. In the end there is nothing like going to bed with a feeling of a job well done.

 

We have to continuously strive to provide the best medical care and attention to the fighters. Analyzing what we do and improving our current medical policies and protocols should be an ongoing task. The more time I spend ringside, the more I realize that boxing is a unique sport for a physician to be involved in and that the odds are stacked against us ringside.  In the office or hospital/ ER setting, a patient comes to us mostly voluntary seeking help and care. On questioning, he/she gives us a detailed history. The family is at times there to supplement the history. Contrast that to the ringside where on direct questioning, frequently the patient (boxer) and his family (corner) falsely deny that anything is wrong and are often upset and angry that we even dared to ask the question. After a fight is over, it is not infrequent to encounter a boxer and his corner who refuse to go to the ER for medical evaluation. “I am fine doc, I am not going” is the deviant answer. These boxers and their corner staff fail to appreciate that symptoms in some people with head injuries don’t show up immediately! (walking, talking and dying syndrome). That is the reason why physicians recommended to observe people after a head injury for 24 hours.

 

When I last checked, none of us physicians have X-ray vision so how are we expected to make a medical call from a distance without the benefit of an honest history or a quick examination?  Many do not realize that once a brain bleed has occurred and the pupils are unreactive (fixed) and dilated, there is precious little we physicians can do ringside to “save” that athlete. Even if that athlete reaches the hospital alive in a timely fashion as a result of our collective efforts, the resulting decompressive surgery is carried out as a last ditch palliative life-saving procedure. That athlete shall never be the same again and will have significant residual neurological deficits. Our goal should be to prevent such a devastating injury from ever occurring in the first place and not just to manage it after it has unfortunately occurred.

 

A few years ago, I wrote a short letter  titled “Boxing can be made safer” in response to an editorial in a leading neurology journal calling for a ban on boxing and MMA. I argued passionately that boxing and MMA can be made safer with improved medical policies designed to protect the health and safety of the combat sport athlete. I still stand by my stated position that boxing can be made safer but the change has to come from inside. In the National Football League (NFL), the culture has already changed from a previously held view of “suck it up and shake it off” to one of “if you feel something, sit it out“. Athletes are now encouraged to report their symptoms of concussion/traumatic brain injury (even if minor and subjective) to the athletic trainers and doctors on the sidelines.

 

The word “No mas” (Spanish for “No more”) gained boxing notoriety when Sugar Ray Leonard fought Roberto Duran II on November 25, 1980. At the end of the eighth round Durán turned away from Leonard towards the referee and quit by apparently saying, “No más“.  Duran’s stature was never the same again after he uttered those 2 words. Over the years, the boxing culture has evolved to one of never saying “No mas”. The fighter’s mentality is never to quit no matter what the circumstances. Doing so brings disgrace to the fighter, his family and his corner. This mentality and culture needs to change, Boxers and corner staff should be educated and encouraged to actively recognize and report to the ringside physician any subjective symptoms of concussion and TBI such as headache, subjective feeling of dizziness or light headedness, blurring of vision, double vision, confusion and a feeling of fogginess. “When in doubt, sit it out” is not equivalent to “No mas”. “For he that fights and walks away, may live to fight another day” historically attributed to Demosthenes, a Greek orator should be the new mantra of boxing. There is no shame in this; just smartness.

 

The boxing culture needs to change and this change shall come over time with education. As physicians it is our duty to educate the boxing community and I hope physicians who practice ringside medicine shall join me in this effort.

 

Together we can make a difference and making boxing safer.

 

 

 

 

 

Good versus bad medical stoppages in boxing-stopping a fight in time

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Good versus bad medical stoppages in boxing-stopping a fight in time

 

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

 

 

 

In boxing it is commonly said and not without reason “the fight must go on….”.  Everyone ringside wants the fight to go on-the two boxers and their corners (sometimes not always!), the promoter (always!), the media (always!), the spectators (always!), the Commission and its appointed officials (only if both the boxers meet the Commission requirements for a fair and honestly administered contest), the referee (only if the boxers are fighting a fair fight and able to defend themselves), the judges (usually do not interfere with the conduct of the fight!) and the ringside physicians (only if the boxers are medically fit before, during and immediately after the contest!). So everyone ringside want the fight to go on but do some (media, spectators and promoters) want it more than others? As per the Uniform Boxing Rules (approved August 25, 2001, Amended August 2, 2002, Amended July 3, 2008), the referee is the sole arbiter of a bout and is the only individual authorized to stop a contest. In some states in the United States and in countries around the world both the referee and ringside physician are the sole arbiters of a fight and are the only individuals authorized to enter the fighting area at any time during competition and authorized to stop a fight. The referee and the ringside physician threshold to stop a fight (enough is enough!!!) may vary based on knowledge of boxing rules and regulations, knowledge of the boxers fitness level, pre-existing medical conditions, pre-bout fitness, intra-bout fitness and finally knowledge of medicine and bout ending injuries (head injuries, orthopedic injuries, eye injuries, blunt abdominal trauma). That is the reason why it is the referee (someone who has knowledge of boxing rules and regulations) and the ringside physician (someone who has knowledge of medicine) who are deemed to be the sole arbiters of a bout and entrusted with the health and safety of the boxers. The other MORE important question is when should the fight be stopped on medical grounds? Stopping the bout prematurely is unfair to the boxers, their corners, the promoter and the public. Stopping a bout too late risks serious injury even death of the boxer.

Boxer safety should precede all other considerations. The goal should be to stop the bout before a life threating injury or career ending injury occurs. Key word is before NOT after. Since at times this is not possible so more realistic goal should be timely identification of a serious injury in the ring and timely stoppage of fight. For that to occur the referee and the ringside physician should work as a team complimenting each other’s knowledge. Causes of sudden death in the ring or in the immediate aftermath of a bout are usually neurological.

To help timely identify and prevent TBI in boxing the following good practice guidelines are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:

 

  1. It is a good point to remember that boxers rarely if ever voluntary quit or request the fight to be stopped. They fight for pride, at times at the expense of their health. Corners may also not want the fight to be stopped with the hope that their boxer may turn things around. In a closely contested fight the crowd is excited and wants the fight to go on. At these times, the ringside physician should make the call to stop or let a fighter continue, based solely on the medical condition of the boxer.

 

  1. During the one minute rest period in-between rounds, the ringside physician should step up to the ring canvas for a quick but thorough medical evaluation of the fighter.

 

  1. This is the ideal time for the ringside physician to assess the neurological status of a fighter. In the case of a fighter who suffered a knock down in the preceding round or sustained multiple head shots, the ringside physician should conduct a quick visual evaluation of the fighter (Is the fighter responding appropriately to the commands and directions of his corner? Is he making eye contact with his corner staff? Was the fighter steady on his feet as he walked back to his corner at the end of the round? Does the fighter voice any complaints to his corner staff such as headache or pressure in head, dizziness, and blurred vision?). The ringside physician should attempt to do the above without obstructing or imposing on the corner’s time with its fighter.

 

  1. If the ringside physician determines that he/she needs more time to evaluate the neurological status of a fighter, he/she should communicate this to the referee. The referee after starting the bout shall call a time out and walk the fighter to the ringside physician to be examined. The referee directs the other fighter to remain in the neutral corner. The ringside physician’s goal at this time is to conduct a quick but thorough neurological assessment of the fighter. He/she should begin this by asking the fighter few leading questions such as-how do you feel? Does your head hurt? Do you know where you are? If the fighter appears confused and disoriented, the ringside physician may ask more question like which round is it? Who is your opponent? Where are you fighting (name of the venue)? The ringside physician should then look for pupil symmetry and response and assess extra ocular movements (have the fighter track finger from side to side). The ringside physician should give the fighter a complex command such as touch your left ear with right glove and should assess the fighter’s gait and balance at the same time (is the fighter steady on his/her feet or is he leaning on the ropes for support). The ringside physician should then communicate to the referee whether the fighter can continue or the fight should be stopped. The whole process should not take more than 10 seconds.

 

  1. The ringside physician should be aware that too much time spent evaluating the fighter during time out, inadvertently gives the fighter more time to recover. The opponent’s corner rightfully resents this and it is akin to getting “saved by the bell”. The public, TV audience, press and TV announcers question the fairness of the Commission’s administration of the contest and the credibility and impartiality of the bout officials-e.g., referees, judges and ringside physicians.

 

  1. If serious health concern is raised for a fighter and the ringside physician is unable to document a good exam to determine whether it is safe for the fighter to continue, consideration should be given to stopping the fight. In these circumstances the ringside physician should tell the referee that the fight be stopped on medical grounds.

 

  1. For ringside physicians with limited ringside experience, it is encouraged that they consult with other ringside physicians at the venue and the chief medical officer before deciding to stop a fight on medical grounds.

 

 

 

 

 

 

 

 

As injuries mount, the boxing community is looking within and the sport is under scrutiny from the medical community and media. Boxing is the most controversial sport for physicians and neurologists in particular because of the potential risk and degree of neurologic injury, questions and concerns about long-term sequelae (chronic traumatic encephalopathy), and the occurrence of deaths in the ring  . Various medical associations including the American Medical Association and the American Academy of Pediatrics have stated opposition to both amateur and professional boxing . Many have called to ban boxing altogether . Dr. Hauser in a recent editorial titled “Beaten into action: a perspective on blood sports” says that “the medical, and especially the neurology, community has an obligation to do more. We need to spread the word that brain bashing is not a socially acceptable spectator sport, and partner with our national organizations to expand and improve the effectiveness of public awareness and other educational initiatives.” He further goes on to state “we should forcefully counter articles in the medical literature taking the position that closer medical supervision could obviate the need for a ban, or even worse that consenting adults have the ethical right to maim each other if they choose to do so .” While the neurological risks of boxing cannot be completely eliminated, boxing can be made safer .

 

 

 

Conclusion

 

 

It is recommended that the above proposed best practice guidelines be debated vigorously by the ringside physician and large scientific community and evidence based guidelines on medical stoppages be developed by the medical community in conjunction with professional boxing governing bodies. Boxing can be made safer but it shall be foolhardy to forget that frequently there is a very fine line between a good medical stoppage (medical stoppage done at the right time during the bout and for the right indication) versus a bad medical stoppage (medical stoppage done either too late, too prematurely or for the wrong indication). It is far better to stop a fight early rather than late. A ringside physician should never forget that in boxing one punch can change everything. One punch can kill!


 

Concussions and the risk of post-traumatic epilepsy

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Concussions and the risk of post-traumatic epilepsy

 

A concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Immediately following a concussion, an athlete is usually advised physical and cognitive rest till post-concussion symptoms abate. The athlete then enters a stepwise return to play protocol. Premature return to play risks a second concussion, second impact syndrome, exacerbation and persistence of post-concussive symptoms.

 

Sports and Epilepsy

Sport is important not only in normal healthy populations, but also in persons with medical illness, physical or mental disabilities. Active participation in sports is beneficial physically and psychologically. The main concern in sports for persons with epilepsy is safety.

 

Why are people with epilepsy restricted from some sports?

 

Rationale is that the occurrence of an untimely seizure during certain sporting event has the potential for causing substantial injury and bodily harm both to the patient with epilepsy as well as fellow athletes and even spectators.

 

Example: if a person with epilepsy has a generalized convulsion or a complex partial seizure while skydiving: he shall not be able to deploy his parachute and a fatal accident can occur.

 

:a person with epilepsy taking part in an automobile racing event suffers a seizure while making a bend at speeds in excess of 100mph

 

:a person with epilepsy suffers a seizure while taking part in a swimming meet.

 

:a person with epilepsy suffers a seizure while bicycling

 

:a person with epilepsy suffers a seizure while horseback riding

 

:a person with epilepsy suffers a seizure while skiing down a steep hill

 

:even things more mundane such as having a seizure while running on a treadmill, while playing tennis, while jogging outside have the potential to cause bodily harm to the patient and others.

 

 

Why are people with epilepsy restricted from some sports?

 

Rationale is that repeated injury to the head (concussions) during some sports could potentially exacerbate seizures.

Example: a person with epilepsy who is indulging in contact sports such as boxing, karate, kick-boxing, muay thai boxing, American football, ice-hockey, wrestling, judo

 

But are these restrictions and fears actually based on scientific evidence or are they unfounded? Which sports are safe and which are not? Could indulgence in some sports make seizures potentially worse Vs. could some sports actually be beneficial for people with epilepsy (physically and psychologically)? Can vigorous physical exercise provoke seizures?

 

 

Exercise and seizures

 

One reason that people with epilepsy have been traditionally restricted from certain sports is the fear both in the patient and the treating physician that exercise especially aerobic exercise may exacerbate seizures. Some studies have shown an increase in interictal discharges during or after exercise. Most frequently these patients have generalized epilepsies. At least some frontal lobe and temporal lobe seizures are clearly precipitated or at times solely occur during exercise suggests that these are a form of reflex epilepsies. A number of physiologic mechanism by which seizures may be provoked by exercise have been postulated. These include hyperventilation with resultant hypocarbia and alkalosis induced by exercise. Another possible mechanism which is postulated to cause exercise induced seizures is hypoglycemia. This usually causes seizures after exercise in diabetic patients. Other mechanisms which have been postulated for exercise triggered seizures include the physical and psychological stress of competitive sports and potential changes in anti-epileptic drug metabolism. Exercise is a complex behavior and involves not such the motor system and the motor cortex but also involves other domains such as attention, concentration, vigilance and presumably some limbic networks which mediate motivation, aggression and competitiveness. Hence it is possible that patients who have temporal or frontal lobe epilepsy may on rare occasions have seizures triggered by exercise.

 

There is some limited evidence that exercise may in fact be protective and have physical, physiological and psychological benefits in patients with epilepsy. Electroencephalographic studies have shown that inter-ictal epileptiform discharges either remain unchanged or may decrease during exercise so there is some hint that exercise may actually raise the seizure threshold. Regular exercise also influences neuronal and hippocampal plasticity by upregulation of neurotropic factors. There is further evidence to suggest that regular physical exercise can improve the quality of life, reduce anxiety and depression and improve seizure control in patients with chronic epilepsy.

 

 

 

 

 

 

 

 

What sports are off limits for people with epilepsy?

 

No sport is completely off limit for a patient with epilepsy. Key though is proper supervision to reduce the potential for injury. There are some sports such as skydiving, automobile racing, swimming in the open seas and horseback riding which should be avoided by patients with epilepsy. Other sports can be enjoyed by patients with epilepsy but one should remember that they all have the potential to result in bodily harm if seizures occur when the patient is not supervised or if he is not wearing protective head and body gear.

 

 

Concussion and seizures (post traumatic epilepsy): what is the link?

 

The link between concussion (closed head trauma) and seizures has been and continues to be closely looked at. The fear of concussions (minor head trauma) making seizures worse is the prime reason why people with epilepsy are discouraged from some sports such as tackle football, ice-hockey, boxing, mixed martial arts and wrestling. The human skull is quite resilient and the closed head trauma has to be significant for it to result in seizures. Usually a concussion which results in prolonged loss of consciousness (some authors say more than 30 minutes) is graded as a significant head trauma. Minor bumps and bruises to the head do not cause seizures, do not increase the risk of future seizures and more importantly do not make chronic epilepsy worse. Seizures may occur immediately following a severe closed head trauma. Immediate post traumatic seizures by definition occur within 24 hours of the injury. They have also been referred to as impact seizures. Early post traumatic epilepsy refers to seizures which occur about a week to 6 months after the injury. Seizures may occur as far out at 2 to 5 years after head trauma (late post traumatic epilepsy). Factors which increase the risk of post traumatic seizures/ epilepsy include severity of trauma, prolonged loss of consciousness (more than 24 hours), penetrating head injury, intra or extraaxial hemorrhage, depressed skull fracture and early post traumatic seizures.

Counseling patients

 

Patients with epilepsy should be encouraged to exercise and take part in sports. My personal feeling is that no sport should be off limits to them with the exception of maybe sky-diving, river rafting and boxing. The goal should be exercising and playing sports safely. Walking, running, cycling and yoga are great exercises which can be indulged in with little to no risks. I advise all my patients with epilepsy (especially those with poorly controlled epilepsy) to wear a Medic Alert bracelet or carry a card in their wallet. This is of immense help were a seizure to occur in the field (as for example when a patient is jogging or cycling and is not in the immediate vicinity of his or her home). Low risk recreational sports such as walking or running usually do not need a one is to one supervision if seizures are well controlled by history. Team sports such as volleyball, basketball, baseball and softball are popular sports which carry a low risk of injury. For cycling I advise my patients to wear a helmet and have their bikes fitted with lights and reflectors. I also advise them to keep off from the busy city streets. “you do not want to have a seizure at the wrong place and at the wrong time”. Swimming is a great way to keep fit and also to meet and make friends. I feel many patients with epilepsy are discouraged from swimming due to an irrational fear of caregivers and physicians of drowning. I advise my patients not to swim alone. Most of the city pools have life guards and a polite request to them to keep a watch out goes a long way in reassuring both the patient and the caregivers. Swimming in the open seas is more risky. I advise my patients to swim close to the beach under the watchful eyes of a life guard. Also having a buddy around helps, preferably someone strong enough to pull the patient out of the water if a seizure was to occur. The option of wearing a life jacket is under utilized.

 

Final thoughts (a patient’s perspective)

 

These are the thoughts of a young patient of mine:

 

“I have always been a very active person and love playing sports such as Tennis, Yoga, Running etc, and I always try to pursue my dreams and not let things get in the way, but being epileptic, it is sometime hard to not worry about things happening. Whenever I play sports I get hot easily (face turns purple) and in the back of my head I find myself always hoping that nothing happens that would cause me to have a seizure. I ran my first half marathon two years ago, and in the back of my head there is always the thought of something happening, so I started to motivate myself by saying “I can do this, you will be fine.” My father taught me when I was younger that I can choose to let it hold me back or make the most of life! Many people consider epilepsy a disability, but I try not to because I don’t let it hold me back.”

 

 

Nitin K Sethi, MD, MBBS, FAAN Assistant Professor of Neurology New York-Presbyterian Hospital Weill Cornell Medical Center

Post Traumatic Epilepsy: when head trauma leaves behind a seizure disorder

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Recently I have seen a few patients with post traumatic epilepsy and hence I decided it might be appropriate to talk about the same in more depth.

Before we begin though I want to wish all the readers of my blog from around the world a very Happy and Healthy New Year 2012. May it bring you not just a healthy brain but also a healthy mind.

Ok now to the topic at hand. Just what do neurologists and neurosurgeons mean when they say you have post traumatic epilepsy? As the name suggests post traumatic epilepsy (PTE) refers to epilepsy/seizures starting after a patient sustains head trauma. Let me explain with an example. Let us assume John is involved in an motor vehicle accident. While driving down the FDR drive late one night he falls asleep behind the wheel of his car. The roads are icy! John’s car spins out of control, jumps the curb and hits an embankment.  John who is not wearing a seat belt gets thrown out of the car striking his head first on the windscreen and then on the unyielding asphalt concrete. A passerby witnesses the accident and calls 911. EMS are on the screen within minutes but John is not moving. His neck is stabilized in a hard collar and he is rushed to the nearest hospital. Glasgow coma scale  (GCS) on arrival is documented to be 5. John is not responding to verbal commands and is rushed to the CT scanner for a stat head CT. CTscan shows all is not well. John has sustained significant head trauma. He has a fracture of the right temporal bone and an underlying epidural hematoma. There are bilateral frontotemporal contusions which are increasing in size. In addition there is diffuse subarachnoid hemorrhage. The epidural hematoma is evacuated that night itself by the neurosurgeon on call. It is decided that at present the frontal lobe contusions be closely observed. John is transferred to the neurological ICU where he is further stabilized. A close watch is kept on the intracranial pressure.

Fast forward 3 weeks.

After a rocky course in the neurological ICU, John makes a remarkable recovery taking the extent of his head injury into consideration. He is discharged from the hospital to a rehab facility skilled in traumatic brain injuries (TBI). In the rehab facility John makes a slow but steady progress. It is 12 noon and John as usual is working with his physical therapist. He suddenly stops what he is doing. Utters a loud guttural sound, falls down to the floor with his eyes rolled up. The therapist notes that he stiffens up for a few seconds and then starts to shake while frothing at the mouth. The whole seizure lasts for about 2 minutes and then subsides on its own. Post seizure John is confused and disoriented but slowly returns to his baseline in about 40 minutes. An appointment is made for John to see Dr. Feelgood a neurologist in the nearby community hospital.

Dr. Feelgood takes a detailed history and then examines John. You have post traumatic epilepsy John, he says and recommends that John consider starting anticonvulsant therapy without further delay.

The scenario I describe above is unfortunately not uncommon in patients who sustain significant head trauma. In fact head trauma is one of the leading causes of epilepsy in men and women below the age of 40 around the world. The human brain is well protected by an extremely rigid skull and so the trauma has to be significant to cause brain damage and resulting PTE.

MINOR BUMPS AND BRUISES TO THE HEAD DO NOT LEAD TO POST TRAUMATIC EPILEPSY. Post traumatic epilepsy is thus very rarely reported after closed head injuries aka concussions such as those sustained on the sport fields(please read my post about concussions either here or on my website http://braindiseases.info). On the other hand PTE is particularly common after penetrating head injuries such as gun shot wounds to the head or when the skull bone is fractured (especially depressed skull fracture where the bone fragment presses on the underlying brain) or when there is significant intracranial bleeding (remember what John’s CT scan showed: blood in the epidural space and hemorrhage into both the frontal and temporal lobes).

Seizures can occur at any time after a significant head injury. The patient may start having seizures immediately after sustaining the head injury. This is called early post traumatic epilepsy and at times this has a more favorable prognosis. After the blood in the brain goes away and the swelling/pressure in the brain subsides, the seizures may also stop spontaneously. Hence these patients may not need to remain on an anticonvulsant medication for a long time. Seizures though have been reported as far out as 5 years after the head injury. This is called late post traumatic epilepsy and these patients usually need to take anticonvulsant medication for a prolonged duration, at times even lifelong.

Depending on the extent of head trauma, seizures may be easy or hard to control in these brain trauma patients. They are usually prescribed anticonvulsant therapy and seizure control is then closely monitored. If seizures persist then a second or third anticonvulsant may be indicated.

Dr. Feelgood started John on a seizure medication by the name of levetiracetam. He advised John to follow up with him after 3 months. On the 3 month follow up visit, John walked into Dr. Feelgood’s office unaided and with a broad smile on his face.

I feel good, Dr Feelgood he said.